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In December 2016, his family started noticing he had problems concentrating and getting out of bed. Things turned for the worse, and Sam struggled to sleep.

Sam was only 23 years old when he died

He started buying sleeping pills called Zopiclone online, but had over dosed in July last year after taking too many tablets.

His family took him to see his GP – the court heard he did not like going to the doctor’s – and he was referred to A&E at Southmead Hospital. After he was seen by mental health services, they referred him again to an ADHD specialist to get a proper diagnosis.

But his GP, Dr Luke Parker from Close Farm Surgery, told the court the waiting list was “months-long”.

Sam’s family was starting to get worried. He had started using cannabis and cocaine to deal with his mental health issues, and he was struggling to sleep, waking up in the middle of the night and turning lights on in the house.

His family wanted to get him sectioned under the Mental Health Act, which mean he would be taken into custody by police, but they would not be able to do so because he did not have a diagnosis.

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On September 18 last year, the court heard Sam had spent the day before on drugs and alcohol. He went to his partner’s house in Knowle, where they had an argument.

Sam went into the kitchen, poured petrol on himself and threatened to set himself on fire. He did so when he sparked his cigarette lighter, and he ran out of the house into the street.

His neighbour told the police in a statement he had seen Sam in flames and took a blanket out to the street and hugged him to try and put out the flames.

Part of the home was burned while Sophie took her young daughter and pet dog to the car to protect them.

Sam was taken to Southmead Hospital

The court heard paramedics had to wait for the all-clear by police before they could treat Sam. Most of the flames had been put out, but the burns had affected more than half of his entire body.

He told his neighbour: “I poured petrol over myself. I’ve been an idiot but I didn’t mean to do it.”

Medics took him to Southmead Hospital, but he was then taken to Morriston Hospital in Swansea the following morning.

The inquest was told Sam was put in an induced coma and he needed to be resuscitated on September 23. He was then transferred to the Royal Brompton Hospital in Chelsea, London, but he died the following day.

Questions

His aunt, Lisa Brice, was in court and asked if her nephew could have been sectioned under the Mental Health Act by the police for his safety.

But both investigating officer Detective Constable Elisabeth Howell and GP Dr Luke Parker said he would not have been taken into custody because he was not diagnosed.

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Conclusion

Assistant coroner Terence Moore said: “I heard from the detective constable that the police powers were not sufficient at this stage for him to be sectioned.

“He was suffering from his ADHD and having to wait for the assessment.

“The other factor is his use of cocaine and cannabis. I can’t comment on this except to say the family suggested to me Mr Brice recognised that drug use was not helping his condition but making it worse.”

Avon Coroner's Court

The cause of death was given as pneumonia and pulmonary thromboembolism caused by the burns.

Mr Moore added: “It was an impulsive act aimed at seeking attention rather than killing himself. On the grounds of probability, I would say this was a death by misadventure.”

Most people who are thinking of taking their own life have shown warning signs beforehand.

These can include becoming depressed, showing sudden changes in behaviour, talking about wanting to die and feelings of hopelessness. These feelings do improve and can be treated.

If you are concerned about someone, or need help yourself, please contact the Samaritans on 116 123.